Diagnostic test results. What do you tell the patient?

[dudette10]

This is a subject I'm still confused about. Let's say you have patient that has gone for diagnostic tests. The results are available, and you know what it says. The patient or family asks about the results.

I've had some nurses say to tell the patient, and I've had others say that's the doctor's job and out of our scope to interpret diagnostics for the patient or family.

This is what I do, and I hope you can give me feedback on whether it's right or wrong. If the official diagnosis has been made, I'll tell them that's what the diagnosis is. "You have pneumonia, and the doctor has ordered antibiotics that I will be giving as scheduled." If the doctor has not yet made a diagnosis, I'll explain that the results of the diagnostics will be interpreted by the doctor and that the doctor will talk to them about the results. "The lab test is usually done to determine if you have a respiratory infection, given your history and your symptoms. The doctor will be able to explain the results to you on his rounds."

What do you do?

[MomRN0913]

If the test is clearly negative (CT scan, MRI) for what they are ruling out, I will tell them that. Diagnosis on these other hand, the docs can do that.

[Anna Flaxis, BSN, RN]

I generally try to avoid divulging lab and diagnostic imaging results to patients. I tell them that the doctor is the one who needs to interpret the results and make the diagnosis. If everything looks WNL, I might say something like "Well, I don't see anything out of the ordinary, but I could be missing something, so I really need to let the doctor discuss the results with you" (if results are negative). If results are positive, I simply tell them they have to wait for the doctor to come talk to them.

However, if it's a person with CKD and they want to know their Cr, I will tell them. Or if it's a person on Coumadin who wants to know their INR, I will tell them. If it's a person with diabetes who wants to know their serum glucose (because our CBG machines only go so high), I will tell them the number.

For an imaging study, I might tell them "It looks like a fracture, but I really need to let the doctor talk with you about it", or "I don't see a fracture, but I'm not qualified to interpret x rays, so I need to let the doctor talk to you about it".

It really *is* the physician's job to discuss lab and imaging studies and answer patient questions.

[xtian]

Anyone know the legal side of this? I would love to advocate for the pt and tell them this or that, but that isn't really something for us to reason. To me it seems these areas with no clear definitions are what get us a seat in court. I have never seen this clearly defined by the BON I was told to follow the hospital policy.

[Esme12, ASN, BSN, RN]

"what did the physician tell you?" sometimes they already did explain it, and you now get to reinforce/correct misapprehensions.

there are plenty of things that patients, particularly ones with long-term illnesses they've been managing, know already. if they ask you, tell them their crits or their amylases or their cd4s....

as for me, if i ever have a nurse say, "oh, you'll have to ask the doctor about that," i'd spit in her eye. i actually did have one say that to me when they brought me my newborn with ekg suction-cup hickeys all over her tiny chest after i had already refused permission to do one, because the only reason she was relatively bradycardic (118) was because she was breastfeeding and i was getting dilaudid for my necrotizing fasciitis (thanks, july house staff, for the through-and-through stitches into dirty places!). there was nothing on it, of course. people are entitled to have their questions answered timely, about their own bodies or those of their children/wards.

you can certainly say, "your potassium was a bit lower than normal this morning, so i'm giving you a bit extra," or, "the xray report (which is read by a physician) says it looks like you have a little pneumonia in there (if that's all it is)," and if you can't figure out how to interpret a finding, tell them that. but none of this dancing around and playing dumb.

man you remind me again........:bowingpur:bowingpur:bowingpur

[nerdtonurse?, BSN, RN]

All states and facilities are different. What I was told in nursing school and later during orientation at both places I've worked is that in my state, a nurse cannot release clinical results to a patient without a MD's approval and signed HIPAA paperwork. In my hospital, with certain doctors, you better not even tell a diabetic what their blood sugar is or they'll be all up in your boss's office yelling about "practicing medicine without a license" and "HIPAA violation." We had a nurse read the interpretation of a CT to a patient, and she was sent home for 3 days for a HIPAA violation. And it was a "everything's normal" CT!

Is it dumb? You betcha. I've had patients scared out of their wits, called the doc and told them and ask if I could read an impression to them, and got my backside chewed. I've had other docs who said, "sure, of course" -- and I wrote the order, "read impression of CXR to patient."

A lot of this probably depends on your state's nurse practice acts, your facility's interpretation of HIPAA, what floor you work on (I don't think telling someone their baby's a girl would be a violation, but one of the ICU docs I work with would think it was) and the doc. Just another stroll thru the lovely minefield we call "nursing."

[Esme12, ASN, BSN, RN]

all states and facilities are different. what i was told in nursing school and later during orientation at both places i've worked is that in my state, a nurse cannot release clinical results to a patient without a md's approval and signed hipaa paperwork. in my hospital, with certain doctors, you better not even tell a diabetic what their blood sugar is or they'll be all up in your boss's office yelling about "practicing medicine without a license" and "hipaa violation." we had a nurse read the interpretation of a ct to a patient, and she was sent home for 3 days for a hipaa violation. and it was a "everything's normal" ct!

a lot of this probably depends on your state's nurse practice acts, your facility's interpretation of hipaa, what floor you work on (i don't think telling someone their baby's a girl would be a violation, but one of the icu docs i work with would think it was) and the doc. just another stroll thru the lovely minefield we call "nursing."

whether or not to give a patient their own labs is a matter of policy and state law. releasing to the patient their own medical information is not a violation of hipaa but maybe a violation of law. releasing a lab result, may be a breech of policy and be grounds for disciplinary action but it is not an actual violation of hipaa. i do however agree that the hipaa paperwork should be signed and if fact has to be signed for the patient to be treated as it gives permission to treat and bill the insurance co. the law prohibits the release of labs directly from the lab to patients and is not clear about the release of labs by nurses

the data privacy rule under hipaa (health insurance portability and accountability act) allows patients to request access to their medical information. at the same time, however, laws in some states prohibit clinical laboratories from releasing laboratory test results directly to patients. the clinical laboratory improvement amendments (clia) require that facilities follow state law and, where state law is more strict than hipaa, labs are not permitted to release test results to the patient. the hipaa needs to be signed so that you are giving permission for the md to order the test, the nurses are able to enter the test with your information to the computer to order the lab to perform the test and the lab needs it signed that you give permission to release the results to the md/nurses when the test is complete. hipaa protects your information from being used by unauthorized person without your specific permission.

state individual laws do however make a huge difference

if state law does not prohibit quest diagnostics from releasing test results to you, you may fill out a quest diagnostiics request for access form to request a copy of your test results directly from quest diagnostics. details on how to request a copy of your test results can be found in our online notice of privacy practices.

http://www.questdiagnostics.com/privacy_practices.html

although this may soon change........

patients may soon be able to get medical test results directly from labs rather than through their health care providers, according to new rules proposed monday by health and human services secretary kathleen sebelius.

the clinical laboratory improvement amendments of 1988 (clia) do not allow test results to be transmitted directly to patients unless the lab is located in a state that explicitly allows this to occur. (currently, 39 states bar labs from providing results directly to patients.)

the proposed rule changes would modify clia to specify that test results are to be released to patients upon request and amend a section of the health insurance portability and accountability act of 1996 (hipaa) that allows patients access to their health records but makes an exception for test results from clia-certified labs.

http://www.hcplive.com/articles/hhs-proposes-to-allow-patients-direct-access-to-lab-test-results

https://www.cms.gov/apps/media/press/factsheet.asp?counter=4079&intnumperpage=10&checkdate=&checkkey=&srchtype=1&numdays=3500&srchopt=0&srchdata=&keywordtype=all&chknewstype=6&intpage=&showall=&pyear=&year=&desc=false&cboorder=date

http://www.hcplive.com/articles/hhs-proposes-to-allow-patients-direct-access-to-lab-test-results

under the current clia regulations, clia restricts a lab’s disclosure of lab test results to one of three categories of individuals: the "authorized person," the person responsible for using the test results in the treatment context, and in the case of reference labs, the referring lab. clia defines an "authorized person" to be the individual authorized under state law to order or receive test results, or both. although many states do not expressly prohibit the lab from providing the test results directly to the individual patient, many of such states only expressly provide for the provision of lab test results to the ordering physician and remain silent on whether the lab can also provide the test results to the patient. accordingly, state regulators in some of these states have interpreted such silence as prohibiting the lab from releasing lab results directly to patients absent an express directive from the ordering physician that such a patient is an “authorized person.” as also noted above, many other states expressly prohibit the provision of test results directly to the patient.

http://labmed.ascpjournals.org/content/32/11/661.full.pdf see page 2 it's a map of regulations by state. but all of this applies to the labs direct release and nurses are considered "authorized persons". which places the question straight back to......check you hospitals policy and procedure manuals and if i got fired for releasing a patient their own information...i'd get a lawyer. this is a complicated issue but i feel the responsibility lies at the md's door for most test results other than....what's my glucose and few other exceptions.....the rest is up to the md. that's what he gets the big buck for. i think this is further complicated by the instant gratification phenomenon in our society with instant messaging and text.

[bjaeram]

All states and facilities are different. What I was told in nursing school and later during orientation at both places I've worked is that in my state, a nurse cannot release clinical results to a patient without a MD's approval and signed HIPAA paperwork. In my hospital, with certain doctors, you better not even tell a diabetic what their blood sugar is or they'll be all up in your boss's office yelling about "practicing medicine without a license" and "HIPAA violation." We had a nurse read the interpretation of a CT to a patient, and she was sent home for 3 days for a HIPAA violation. And it was a "everything's normal" CT!

Is it dumb? You betcha. I've had patients scared out of their wits, called the doc and told them and ask if I could read an impression to them, and got my backside chewed. I've had other docs who said, "sure, of course" -- and I wrote the order, "read impression of CXR to patient."

A lot of this probably depends on your state's nurse practice acts, your facility's interpretation of HIPAA, what floor you work on (I don't think telling someone their baby's a girl would be a violation, but one of the ICU docs I work with would think it was) and the doc. Just another stroll thru the lovely minefield we call "nursing."

That is ridiculous!! It has NOTHING to do with HIPPA. You aren't sharing the results with the visitors in the hallway you are sharing them with the patient who has every right to know them.

As far as the comments about doctors interepreting xrays. They have already done that. Radiologists read them and that is a doctors interpretation. The admitting MD often doesn't even look at them. I have no qualms sharing that. I will not discuss plan of care but the results are there in black and white. If its complicated I know I won't have the answers to all of the questions I won't divulge but if it's simple, broken arm...pneumonia...kidney stone....I don't have a problem sharing the result. It relieves anxiety to know what is wrong. I would hope a nurse would do that for me instead of making me wait a day to talk to the doctor.

[MassED, BSN, RN]

The disagreements are as interesting as your own personal stories about how/why you do things.

Pneumonia can be a killer (it killed my stepmother), but it's a dx that doesn't strike fear in a lot of people like ca, MI, or CVA does. We've had patients come up from the ER with PNA as the admitting dx and the PNA protocol started. I feel comfortable saying I'm hanging this abx for PNA, if that is the official dx. Haven't gotten in trouble for it...yet.

nor should you EVER get "in trouble" - I don't understand why that would even cross your mind.... you NEED to know why you are giving a med - and if that is for infection, then you state that. I'd worry if you did NOT know why you were giving a med...

[MassED, BSN, RN]

Anyone know the legal side of this? I would love to advocate for the pt and tell them this or that, but that isn't really something for us to reason. To me it seems these areas with no clear definitions are what get us a seat in court. I have never seen this clearly defined by the BON I was told to follow the hospital policy.

ok, to be CLEAR, you are NOT diagnosing them, just providing information that has already been resulted. What is the problem??? Since when is providing appropriate information an issue? You have to exercise some common sense, as when a new (and potentially catastrophic) diagnosis is made, or if a person has Appendicitis, the doctors go in to provide the diagnosis and tell them the plan. But if it's most anything else, I relay the information - that's all we do - we counsel/teach as well - just make sure you know about the lab results and their diagnosis so you can connect the dots to the patient who may have ZERO medical background and need basic information..... never an issue to provide information/communicate.

[MassED, BSN, RN]

All states and facilities are different. What I was told in nursing school and later during orientation at both places I've worked is that in my state, a nurse cannot release clinical results to a patient without a MD's approval and signed HIPAA paperwork. In my hospital, with certain doctors, you better not even tell a diabetic what their blood sugar is or they'll be all up in your boss's office yelling about "practicing medicine without a license" and "HIPAA violation." We had a nurse read the interpretation of a CT to a patient, and she was sent home for 3 days for a HIPAA violation. And it was a "everything's normal" CT!

Is it dumb? You betcha. I've had patients scared out of their wits, called the doc and told them and ask if I could read an impression to them, and got my backside chewed. I've had other docs who said, "sure, of course" -- and I wrote the order, "read impression of CXR to patient."

A lot of this probably depends on your state's nurse practice acts, your facility's interpretation of HIPAA, what floor you work on (I don't think telling someone their baby's a girl would be a violation, but one of the ICU docs I work with would think it was) and the doc. Just another stroll thru the lovely minefield we call "nursing."

ok, if you're talking about handing a PRINTED copy of a patient's CT/lab results to them, that has to be ok'd by the doctor and documented.

THe person sent home about telling the RESULTED CT to a patient? Must be more to the story, because a HIPAA violation does not occur when you tell a patient about their medical information.... makes no sense.

[kayak133]

I have had lab results shared with myself - as a patient - only if they were normal, and if the receptionist/tech was not able to find a doctor to discuss the results with. I can imagine that the conversation would have run differently if they were not. It is dependent upon what your facility allows. It is a shared responsibility: nurses can educate the patient to the type of test and depending upon the educational and maturity level of the patient and taking into consideration the emotional state of the patient and caregivers as well, what the normal values are and treatments if the results are positive...I would definitely say, if this situation is in a hospital setting, to keep the interpretation of the lab results in the doctors hands. Apologize in advance for any ignorance here, I am student nurse who is sitting on the fence about nursing.

[dudette10, MSN, RN]

In my hospital, with certain doctors, you better not even tell a diabetic what their blood sugar is or they'll be all up in your boss's office yelling about "practicing medicine without a license" and "HIPAA violation."

Wow. That's just weird. Many long term diabetics, especially the ones who are very good at controlling their BS, ask for their readings. I think nothing of telling them. Same for people who've come in with malignant hypertension when I do BPs. How else do I explain the the hydralazine PRN or a change in HTN meds? People who come in with fever NOS always want to know their temps.

MassED, to answer your question about why I would feel I would get into trouble. I think I read here too much.